Delivering yoga to people with hypertension in the UK: A qualitative study to explore yoga providers' knowledge, experiences, and attitudes

Abstract Background and Aims Yoga has become increasingly popular in the world and the UK for improving health and well‐being. A growing body of research suggests that yoga could be used to improve the management of hypertension in addition to current management strategies. Previous cross‐sectional studies have also reported that hypertension is one of the most commonly disclosed health conditions in yoga sessions in the United Kingdom. Therefore, semi‐structured qualitative interviews were conducted with yoga providers in the United Kingdom (n = 19) to explore their knowledge, experiences, and attitudes toward delivering yoga to people with hypertension. Methods Interviews were audio‐recorded, transcribed verbatim, and analyzed thematically. Results Eight themes were identified. Yoga providers were generally aware of the health conditions of their attendees, and they had a reasonable knowledge of the causes, signs and symptoms, and management of hypertension. While most had received some information about hypertension as part of their initial yoga teaching training, this was generally felt to be limited. They mentioned the biopsychosocial benefits of yoga on hypertension but also expressed their concerns about the lack of regulation, the wide disparity in what is being delivered under the label of yoga, and the competency of some yoga providers. Conclusion The findings suggest that yoga provision in the United Kingdom should be regulated with a better link with health service providers. A manual and training for yoga providers in the United Kingdom for managing hypertension using yoga would be helpful to address the training needs of yoga providers. However, there is a need for more robust studies before recommending the implementation of yoga in the management of hypertension in the United Kingdom.

WHAT IS KNOWN 1. Previous systematic reviews showed that yoga may be effective in the management of hypertension.

Previous cross-sectional studies have also reported that hyper-
tension is one of the most commonly disclosed health conditions in yoga sessions in the United Kingdom.
WHAT IS NEW 1. Yoga providers had received some information about hypertension as part of their initial yoga teaching training but this was generally felt to be limited.

| INTRODUCTION
Hypertension or high blood pressure is a global public health concern which is a major risk factor for stroke, myocardial infarction, heart failure, and chronic kidney disease 1 and thus, one of the most important, treatable causes of premature morbidity and mortality in the world. 2 It is highly prevalent, and around one in six people have hypertension worldwide. 3 In the United Kingdom, hypertension is one of the most common health conditions, and around one in four people have hypertension. 4 It is the third biggest risk factor for disease and disability in England after smoking and poor diet. 4 A growing body of research suggests that yoga, a mind-body practice that originated in the ancient Indian subcontinent, could be used to improve the management of hypertension in addition to current management strategies, predominantly, lifestyle modification and antihypertensive medication. Several systematic reviews have shown that yoga can reduce high blood pressure. [5][6][7][8] A recent systematic review and meta-analysis of yoga interventions found that yoga can achieve a 6.49 mmHg reduction (95% confidence interval [CI]: 4.04-8.94) in systolic blood pressure and a 2.78 mmHg reduction (95% CI: 1. 45-4.11) in diastolic blood pressure compared to control. 5 Furthermore, yoga has become increasingly popular 9 and is being used as a therapeutic approach by many attendees to improve their well-being and manage health conditions in the world [10][11][12] and the United Kingdom. 13,14 Previous cross-sectional surveys conducted in the United Kingdom 15,16 and other countries such as the United States and Japan 11,12,17 have also reported that hypertension is one of the most commonly disclosed health conditions in yoga sessions and perceived benefit of yoga for hypertension was high among the attendees. 13,18,19 Yoga is widely practiced in South Asian countries such as India and Nepal and it has been integrated into the health care system. [20][21][22][23] For example, in India, there are initiatives to regulate higher education and practice. There are various levels of yogarelated education in India, including a bachelor's degree, which is a recognized medical course 24 and postgraduate taught and research degrees. 25 There are also some regulations in place to guarantee the quality of yoga sessions. 22,23,26 The Indian government initiated the Scheme for Voluntary Certification of Yoga Professionals, which is monitored by the Ministry of Ayush 27,28 and is creating a regulatory body for higher education and practice. 26,29 In the United Kingdom, yoga is delivered by a combination of yoga teachers and yoga therapists, that is, yoga teachers with additional training and experience in the therapeutic adaptation and application of yoga to those with health issues. 30 Since yoga is largely unregulated in the United Kingdom, yoga teachers may be heterogeneous in their training and skills. Despite yoga's potential benefits for managing hypertension and its popularity among people with hypertension, little is known about the knowledge, experiences, or attitudes of these UK yoga providers in relation to managing hypertension in their sessions. In the process of generating evidence, yoga providers' inputs would be relevant and useful for decisionmakers as yoga providers' views as service providers would help to understand the potential issues in using yoga for the management of

| Study participants and recruitment
All the 404 yoga providers in the United Kingdom who participated in a previous online cross-sectional survey were eligible to take part in this qualitative study. 15 Yoga providers were approached through professional yoga associations in the United Kingdom. Five yoga associations were approached to circulate the survey among their members, and four agreed, namely, the Association for Iyengar Yoga in the United Kingdom and Republic of Ireland, the British Wheel of Yoga (BWY), Complementary and Natural Health Council (CNHC), and Independent Yoga Network (IYN). Yoga providers were provided with information about this qualitative study and contact details of the lead researcher (GN) at the end of the online survey. Twenty-two yoga providers were interested and contacted the lead researcher but three of them did not respond to the follow-up emails. A link to the participant information sheet and consent form, created using Microsoft Forms was emailed to them. They were given at least 24 h to decide to participate in this qualitative study and the date for the interview was arranged. Further verbal consent was taken at the beginning of the interview. Participants were informed that transcripts would be anonymized and treated confidentially and that they were free to withdraw at any point during the interview if they so wished.

| Interview guide
A semi-structured interview guide was developed by the researchers through a series of discussions, based on the aim of the qualitative study. The interview guide was reviewed by a senior qualitative researcher (MB) and revized in line with her recommendations. It was also pretested among two yoga providers (yoga teachers) but no changes were required following piloting. The data from pilot interviews were not included in the study. The interview guide

| Sample size
We intended to interview 20 yoga providers, aiming to achieve saturation of themes (i.e., the point where no new or relevant themes were discovered in the analysis). Saturation is often described as the point in data collection and analysis when new incoming data produces little or no new information to address the research question. 32 However, the saturation of themes was achieved at the 15th interview, and we continued to interview a few more yoga providers to ensure that any important theme was not missed.

| Interview procedures and transcription
All the interviews were conducted by the lead researcher, trained in qualitative research methods, in English using the interview guide.
Interviews were conducted through video conferencing or phone calls due to the COVID-19 pandemic. With the consent of the participants, the interviews were digitally recorded. Field notes were also taken to complement interviews in terms of nonverbal cues such as gestures and the tone and pitch of voice that may not have been adequately captured through the audio recording. Five recordings were transcribed verbatim by the lead researcher (GN) to familiarize herself with the data, and the remaining 14 recordings were transcribed by an external specialist company after signing the nondisclosure agreement. The quality of the transcripts was ensured by the lead researcher listening to the recordings and constantly comparing them to transcripts to rule out the possibility of missing data. Any potential identifiers were removed by the lead researcher and each transcript was labeled with a number.

| Data analysis
Transcripts were imported into NVIVO 12 (QSR International, Australia) software to enable data storage and organization for analysis. 33 Data were analyzed thematically using an inductive approach so that the researchers could determine the important concepts from the participants' perspectives. 34 As an initial step to aid familiarization with the data, the first five interviews were read several times by two independent researchers (GN and ZMH) and then the transcripts were coded line by line. The preliminary codes were discussed between them and if any discrepancies were found, these were discussed with senior study authors (SL and KC). Then, codes were organized into overarching categories, which formed themes. Codes and themes were subsequently discussed among all the researchers resulting in an initial thematic codebook. The preliminary themes were then applied and refined following analysis of the remaining transcripts, which were independently analyzed by the same two researchers (GN and ZMH). All the researchers reviewed themes to ensure that they were distinct and not overlapping. The themes were further considered in relation to the whole data set to ensure they accurately reflected the data set. The analysis was iterative rather than a linear process and all these codes were refined during analysis as the data emerged. Each theme was described with supporting quotes that were chosen based on the best illustration of the notion of the theme. Quotes mentioned in the results section are verbatim unless indicated by an ellipsis (…) to signal that small segments of text have been removed for clarity. Participants did not provide feedback on the findings. yoga providers group in the United Kingdom. Therefore, before attempting to analyze the collected data, she took an effort to grasp the overall scenario of training of yoga teachers in the United Kingdom and she completed yoga teacher training in the United Kingdom and is now a qualified yoga teacher. This helped her to understand the data better, for example, made her familiar with the jargon used by the participants. During the interpretation of data, potential biases were avoided by involving independent senior researchers (SL and KC).

| Participants
Interviews lasted 49 minutes on average. Nineteen yoga providers were interviewed who were generally based in England but some were also delivering online yoga sessions to people in other parts of the United Kingdom. They were delivering yoga sessions in public, private, and public/private settings. The majority of them mentioned that they did not link their practice to a particular school or style of yoga but generally called their style Hatha yoga and some of them mentioned specific branches of Hatha yoga. Yoga providers said that attendees were of mixed abilities, mixed sexes, and mainly adults with a broad range of health issues (Table 1).

| Thematic analysis
Eight themes were identified.

| Theme 1: Awareness of health conditions
Yoga providers generally asked their attendees if they had any injury or health issues at the beginning of each class, or the stage of an individual joining a new class. Some asked for a verbal disclosure of any health issues, whereas others asked them to fill in a written health form. However, some yoga providers added that it was not always possible to ask attendees if they had any health issues, for example in gyms where sessions are drop-in or when collecting health information in written form was not allowed by the center. In addition, the difficulty of asking attendees to disclose their issues in an online class was mentioned as the attendees were only able to see the yoga provider or were muted throughout the session. A variety of health issues were disclosed by attendees to the yoga providers including musculoskeletal issues, mental health issues such as stress, anxiety and depression, hypertension, and cancer.
Stress and hypertension were among the most commonly disclosed conditions along with musculoskeletal issues such as joint or back pain. Most yoga providers reported that at least some of their attendees disclosed hypertension to them and the percentage who did so varied from 1% to almost 100%. It was highlighted that awareness of health conditions was dependent on disclosure, and attendees might not have disclosed hypertension either because they were not aware of it themselves or because they did not perceive it as relevant to mention to the provider.
I've had high blood pressure, low blood pressure, stress, anxiety, depression… A lot of joint problems knees, hips, wrists, and things. (P1) The ones declared, it's quite low…It's not as high as I thought it would be. That's why I think either they're not saying because they think, oh it's not important, or some T A B L E 1 Sociodemographic characteristics of the interviewees. smoking and alcohol consumption, and medication would help in its management. In addition, they noted that yoga and any activity that helps reduce stress helps to manage hypertension.
My understanding is that stress is a key factor in increasing blood pressure.  Yoga's contribution to mental health through its calming and stressreducing effects was especially highlighted by most yoga providers as stress was seen as one of the major contributors to hypertension. It was also added that doing something beneficial for themselves makes attendees feel better and some of them said that yoga enhances the feeling of a sense of community and acceptance, which contributes to emotional well-being.
There is no medical evidence but what there is, a lot of people tell me, they feel better, they use less medication,  health system not yet recognizing the potential of yoga for managing hypertension and other conditions and they expressed that NHS is very slow with coming on board and recognizing yoga as a health management and wellbeing tool. It was exemplified by a yoga provider who was aware of a major research project on yoga for healthy lower backs going on for more than 10 years but still not recognized by the NHS. There are many studies suggesting the effectiveness of yoga interventions for managing hypertension 5-8 but yoga providers mainly were not aware of such evidence which may suggest that they mostly do not incorporate evidence-based findings into their sessions. This is probably because it is difficult for them to locate and utilize the data on the most effective and safe yogic practices. They also tend to lack the knowledge and skills how to critically appraise research articles, therefore, they can struggle to make sense of the results from studies, which are at times contradictory in their findings. 35,36 Thus, a manual and a training program based on the manual for yoga providers in the United Kingdom for managing hypertension would be helpful to address their training needs. However, a previous systematic review found some evidence of the effectiveness of yoga in managing hypertension, but the quality of the included studies was poor. 5 This review also synthesized the heterogenous content, structure, and delivery characteristics of effective yoga interventions used for hypertension management. 5 Therefore, the subsequent step would be to attain a consensus over the findings of this review to develop the intervention (i.e., intervention materials like a manual for yoga providers) and conduct a robustly designed randomized controlled trial (RCT). However, even if a manual is developed for hypertension management using yoga, initially, it may not be feasible to expect all yoga providers to adhere to it. Nevertheless, some yoga providers have searched for evidence on what practices would be helpful or contraindicated for people with hypertension but recognized that there is currently a lack of evidence in this field. This implies that some of them comprehend the concept of evidence-based practices and may still be able to engage in evidence-based practices to some extent.
Yoga providers highlighted the biopsychosocial benefits of yoga for hypertension, which include physical, psychological, and social benefits.
For example, generally, yoga is a non-strenuous activity practiced in a calm environment and a class with a group of people. [37][38][39] These aspects of yoga were perceived by yoga providers to be making it an activity that increases mobility and physical function as well as improving the mental well-being of attendees and providing them with a sense of community.
This is in accord with earlier studies where participants reported increased social connection and more positive relations with others. 19,[40][41][42] In addition, a systematic review and meta-analysis showed that yoga is a reasonably safe and well-tolerated practice with limited adverse events when practiced appropriately. 43 As well as yoga being a potential way of managing hypertension, it may cause concern due to its potential to cause harm. For example, there are more than 20 yoga styles, and specific styles, such as Hot/Bikram yoga, may not be suitable for people with hypertension. 44,45 As suggested by yoga providers in this study, even if the right style is chosen, if yoga is not practiced correctly and under proper guidance, it may lead to adverse events. Similarly, a survey assessing yoga-related injuries found that the most common causes were excessive effort, inadequate training of yoga providers, and improper or inadequate instruction given by yoga providers. 46 Along with the increasing popularity of yoga and the number of yoga attendees, the number of yoga providers has also increased. 14 As there are no nationally set standards for yoga provision in the United Kingdom, 15 people with no adequate training can also use the title "yoga teacher." Though yoga providers showed a willingness to teach yoga to people with hypertension, concerns have been raised about the lack of regulation and the competency of some yoga providers. 47 The lack of regulation may also cause hesitation by health service providers in recommending yoga to their patients. Therefore, to maintain the quality of yoga sessions and to ensure the credibility of yoga providers and the safety of yoga attendees, yoga should be regulated by a formal organization or association for example yoga associations. The lack of regulation is an issue that must be addressed for people with hypertension or other health conditions as well as for people without any health condition (i.e., as part of a healthy lifestyle to prevent diseases).
Yoga is also not regulated in the United States and some other European countries such as Germany, 48,49 however, it appears that yoga has been incorporated into patient care in these countries. 48

| Strengths and weaknesses
To the best of our knowledge, this was the first study that explored Therefore, their views may not be transferrable to yoga providers across the United Kingdom or other settings. Only one yoga therapist was interviewed which provided some insights from this group of yoga providers, but the study predominantly reflected the views of yoga teachers in the United Kingdom. However, the vast majority of yoga is delivered by yoga teachers, 15 and hence if yoga is to be more widely promoted as part of a healthy lifestyle, it is likely to be yoga teachers who need to be trained to deliver what is required.

| Conclusion
Yoga providers showed a willingness to teach yoga to people with hypertension, however, the wide disparity in what is being delivered under the label of yoga and the competency of some yoga providers was a concern to them. Therefore, lack of regulation is an issue that needs to be addressed for people with hypertension or other health conditions as well as for people without any health condition. A manual and training for yoga providers in the United Kingdom for managing hypertension using yoga would be helpful to address the training needs of yoga providers. In addition, a better link between health service providers and yoga providers could be established to overcome the hesitation of health service providers in recommending yoga to people with hypertension and to direct people with hypertension to a yoga session that is suitable to their needs. However, there is a need for more robust evidence before the implementation and regulation of yoga can be recommended across the UK for the management of hypertension.
NALBANT ET AL. Kaushik Chattopadhyay: Formal analysis; writing-review and editing. All authors have read and approved the final version of the manuscript. Gamze Nalbant had full access to all of the data in the study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

ACKNOWLEDGMENTS
We would like to thank Dr. Manpreet Bains for her contribution to developing the interview guide. GN is a PhD student, funded by the Ministry of National Education of Turkey. This research is a part of her PhD project. The funding agency had no role in designing or conducting the study or writing the manuscript.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
A deidentified data set will be available upon request unless there are legal or ethical reasons for not doing so.

ETHICS STATEMENT
The study was conducted in accordance with the Declaration of

TRANSPARENCY STATEMENT
The lead author Gamze Nalbant affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.